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Review Article

Overview of Violence to Self and Others During the First Episode of Psychosis

Olav B. Nielssen, MCrim, PhD, FRANZCP; Gin S. Malhi, FRCPsych, FRANZCP, MD; Patrick D. McGorry, MD, PhD, FRCP, FRANZCP; and Matthew M. Large, MD, FRANZCP

Published: May 15, 2012

Article Abstract

Background: We aimed to review the evidence for an association between the first episode of psychosis and violence and to consider the possible explanations for this association and the implications for clinicians and service providers.

Data Sources: We searched for published studies in English describing an association between violence and first-episode psychosis using the subject headings, key words, abstracts, and titles in PubMed/MEDLINE from 1970 to 2010, using the terms first-episode schizophrenia OR first-episode psychosis OR early schizophrenia AND suicide OR self harm OR suicide attempt OR homicide OR violence.

Study Selection: We identified 20 studies reporting data on violent suicide attempts, self-mutilation, minor violence, severe nonlethal interpersonal violence, or homicide in first-episode and previously treated psychosis.

Data Extraction: The number of people committing acts of violence prior to initial treatment for psychosis and after initial treatment was extracted from the relevant studies.

Results: The proportion of people found to be in the first episode of psychosis at the time of an act of violence was compared to the expected ratio of first-episode to previously treated patients. A substantial proportion of psychotic patients examined after violent suicide attempts (49%), major self-mutilation (54%), homicide (39%), and assault resulting in serious injury (38%) are in their first episode of psychosis. Moreover, a substantial proportion of first-episode patients commit an act of less serious violence or attempt suicide prior to initial treatment.

Conclusions: The findings support the need for early intervention and community-wide programs to reduce the duration of untreated psychosis.

J Clin Psychiatry 2012;73(5):e580-e587

Submitted: April 1, 2011; accepted October 14, 2011 (doi:10.4088/JCP.11r07036).

Corresponding author: Matthew M. Large, MBBS, The Euroa Centre, Prince of Wales Hospital, Barker St, Randwick, NSW, Australia 2031 (

Volume: 73

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